HEALTH HISTORY

2. Is your child allergic to any medications? Food? If so, which ones? PEANUTS?

3. Is there a medication your child should NOT take?

4. Any history of:

Cerebral Palsy
Yes
No

Pneumonia
Yes
No

Stomach Problems
Yes
No

Seizures
Yes
No

Asthma
Yes
No

Ear, Nose, Throat Problems
Yes
No

Convulsions
Yes
No

Shortness of Breath
Yes
No

Skin Problems
Yes
No

Fainting
Yes
No

Kidney Problems
Yes
No

Mental/Nervous Disorder
Yes
No

Head injury
Yes
No

Diabetes
Yes
No

Chicken Pox
Yes
No

Sensory Disorder
Yes
No

Hepatitis A B C
Yes
No

Measles
Yes
No

Anemia
Yes
No

Limited arm/leg usage
Yes
No

Rheumatic Fever
Yes
No

Hemophilia
Yes
No

HIV+
Yes
No

Heart Murmur
Yes
No

Blood Disorder
Yes
No

Malignant Hyperthermia
Yes
No

General Anesthetic Problems
Yes
No

Blood Transfusion
Yes
No

Cancer
Yes
No

Autism
Yes
No

Tuberculosis
Yes
No

5. Are immunizations up to date?

6. Has your child ever been hospitalized? Why?

7. Any concerns about your child's medical history which you feel are important?

8. Has your child been to a dentist before?

Any Problems?

9. Health card number, version code and expiry date

PERSON RESPONSIBLE FOR ACCOUNT

Father's Name

Occupation

Bus.#

Mother's Name

Occupation

Bus.#

Primary Dental Insurance?

Ins. Co. Name

Person Insured?

DOB

Policy/Group#

ID/Certificate#

Division#

Secondary Dental Insurance?

Ins. Co. Name

Person Insured?

DOB

Policy/Group#

ID/Certificate#

Division#

CONSENT FOR TREATMENT/OFFICE POLICY

I consent to all dental procedures discussed with Drs. Benbassat, Goldenberg, or Ramji. I have read, understand and agree with the policies of this office. I assume responsibility for all fees charged for my dental treatment. ALL FEES ARE PAYABLE ON THE DATE OF SERVICE. PAYMENTS MAY BE MADE BY CASH, DEBIT, VISA, MC OR AMEX ONLY. WE DO NOT ACCEPT PERSONAL CHEQUES.